Tewari et al. The procedure involves circumcision with local tumor excision using tangential cuts through the glans or corpora with 3—5 mm margins using CO 2 laser and coagulation of the tumor bed using the Nd:YAG laser. Post procedural defects heal through re-epithelialization and remained open to heal over 7—9 weeks.
If excised near the distal urethra, an indwelling catheter may be used for the first postoperative week. If positive inguinal lymph node metastases are found 6 to 8 weeks postoperatively, full inguinal block dissection is the treatment of choice. Typical postoperative care involves day 1 exam, day 4 wound check and twice weekly wound checks until healing is achieved. Wounds may be reviewed at 3-month intervals to determine healing, urinary function, and potential recurrence In laser treatments, the CO 2 laser may be used for macroscopic excision of the penile lesion with a visible 3 to 5 mm margin.
This would then be followed by the use of Nd:YAG for coagulation of the tumor bed due to its deep penetrating wave property to better eradicate the tumor In a study by Windahl et al.
Cosmetic and functional results were reported to be highly satisfactory, and the option to repeat the procedure in patients with recurrence makes this a good option for conservative treatment. Radiotherapy has been utilized for over 50 years in the treatment of penile carcinoma and may be delivered via external beam or brachytherapy. Circumcision is prerequisite to radiation therapy to ensure full exposure of the cancer.
Poor prognostic factors for response to radiation include total dose less than 60 Gy, T3 or greater tumor, tumors larger than 4 cm, and high tumor grade 49 , 51 - Bulky or deep tumors are usually not amenable to radiation therapy and typically require surgical intervention, except in cases of palliative radiotherapy for extensive disease. Interstitial brachytherapy provides therapeutic comfort to patients as a conservative method of cancer management in this patient population.
The methodology involves Gy over the course of 4—6 days with general anesthesia or penile block with systemic sedation This option offers less trips to have radiation completed and a shorter radiation course than external beam, however, this tends to have a higher potential for incomplete tumor removal. Therefore cancer recurrence is an ongoing concern, as unstable bordering epithelium can remain 41 , Rouscoff et al. In the largest study of brachytherapy, Rozan et al. External beam radiation therapy EBRT has been used as both a conservative therapy and in the treatment of patients with recurrence following brachytherapy.
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In EBRT, one daily fraction of 2 Gy, 5 times every week over the course of 6 or 7 weeks offers a large cumulative dose of radiation. This treatment evenly radiates the affected tissue to reduce tumor burden. The data for EBRT compares well with that of brachytherapy, despite procedural differences in the process of Gy dose delivery over time.
Therefore, penile sparing surgery is of great importance in regards to cosmesis, and functionality, as well as cancer control. The goal of penile cancer treatment is preservation of function and adequate cancer control via tumor resection Data from Romero et al. Therefore the importance of a satisfactory cosmetic, as well as functional, outcome without compromising cancer control cannot be overstressed. When these factors indicate surgery for patients, surgeons must have a keen understanding and ability in performing reconstructive surgery, as well as a scrupulous use of frozen section during excision of adjacent tissues to ensure complete tumor eradication.
Although patients treated with penile preservation experience more local recurrences, data supports the notion that 5-year cancer specific survival is not jeopardized in appropriately selected patient Traditionally, it was believed that a 2 cm negative surgical margin was required in order to attain adequate cancer control with minimal risk of recurrence. However, studies by Agrawal et al. Consequently, preputial tumors may be properly treated by local excision via circumcision with minimal margins with low risk of recurrence, resulting in satisfactory cosmetic results with maximal preservation of normal tissue and function.
MMS is the practice of layer by layer tissue excision until it is cleared microscopically from any cancerous appearing elements The result is maximal tissue cosmesis and function.
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This has been widely used by dermatologic surgeons for excision of cutaneous squamous and basal cell cancers located primarily in the head and neck region. Three major studies evaluated the efficacy of MMS, and all revealed relatively high recurrence rates. Most notably, Shindel et al. However, 7 of the 8 recurrences were successfully managed with repeated MMS Despite the high recurrence rate, the study concluded MMS combined with repeat procedures and vigilant follow-up provided excellent cancer specific and overall survival rates with low risk of disease progression.
Lesions limited to the glans may be treated by various surgical modalities. The extent of penile preservation and resection is based on degree of invasion and the ability to attain negative surgical margins. This may be achieved by glans resurfacing techniques, partial glansectomy with grafting, or total glansectomy with glans reconstruction. As the previous standard of achieving a 2 cm negative surgical margin has not shown any benefit in cancer control, isolated lesions of the glans may be treated with partial glans excision with only a 2 mm margin 41 , 58 , This allows for greater preservation of the glans with excellent functional and cosmetic results while achieving adequate cancer control.
A primary closure may be performed, however, the defect may also be grafted using partial or full-thickness skin grafts from the thigh In patients where the majority of the glans was removed, McDougal reported use of a penile shaft skin advancement to cover the defect with excellent cosmetic result For low grade and low stage tumors of the corona, Brown et al. This technique preserved the distal urethra with normal voiding function and no recurrence in a month follow-up period.
TGR involves utilization of a skin graft after removal of the epithelium and subepithelium of the glans to the level of the corpus spongiosum This technique has been used for BXO and has shown promising results in limited studies for CIS 36 , 68 , with an overall recurrence rate of 4 percent as demonstrated by Shabbir et al.
With urethral involvement or large glandular lesions, a total glansectomy is the treatment of choice 55 , 69 - A split-thickness skin graft with urethral spatulation is performed after exposing the bilateral corpora cavernosa to form a neo-glans 69 , Palminteri et al. Complications noted involve poor graft take and graft-overgrowth with intrusion of the urethral meatus Traditionally, corporal invasion has been treated with partial penectomy with a 2 cm negative surgical margin. The paradigm has now changed with a 10 mm margin for grade 1—2 lesions and 15 mm margins for grade 3 lesions 70 , This has allowed for greater preservation of cavernosa and penile length.
Therefore, small and relatively confined T2 tumors may be managed with excision and grafting with glans reconstruction This emphasizes the significance of glans reconstruction, as it provides satisfactory cosmetic and functional results without compromising cancer control. It is also important to note that multiple studies advocate the use of frozen section during the procedure to attain negative margins 41 , 71 , Deeply invasive SCC of the shaft that does not involve the corpora may be treated more conservatively.
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This is achieved by removal of the skin and subcutaneous tissues with subsequent split-thickness skin grafting. This eliminates drainage areas from which seeding may occur This complements palliative radiation and decreases the burden of wound care and associated skin site infections that cause a drastic increase in morbidity The tensor fascia lata and rectus abdominis flap offer the best closure of wound defects without requiring skin grafting.
Large wounds, fistulization, and previously irradiated areas with need for salvage can benefit from the use of transposing myocutaneous flaps to improve outcomes The flaps are not curative but minimize dramatic complications associated with poor wound healing at the site of the surgery.
Parkash described the use of flaps in groin block dissection for inguinal node involvement of penile carcinoma Block dissections were performed in 17 patients with penile carcinoma using upper sartorius, upper gracilis, and lower rectus abdominis following nodal excision. The skin grafted well in 16 of the cases, with one case of significant necrosis.
The study notes the limitation of sartorius flaps from an anatomical standpoint and that rectus abdominis flaps are the most reliable and should be taken from the side opposite the site of block dissection. In the case of bilateral dissection, a gracilis flap was shown to be most beneficial, as the rectus abdominis flaps must be done contralaterally In another study by Kayes et al. In one case, skin coverage was expanded by tensor fascia lata in a larger surgical excision site. The use of myocutaneous flaps involves a thorough determination of blood supply to the underlying muscle to promote rapid healing and minimize necrosis.
A suitable blood supply from segmental perforators of both the superior and inferior epigastric arteries has been proven to be a critical measure of success in cases of flap reconstruction. Additionally, the superficial inguinal and circumflex iliac arteries may contribute some supporting branches for effective perfusion and successful grafting. The hospital course involves 3 days of strict bed rest with two large bore drains from the site of flap placement The most important considerations for candidates of this surgery include medical clearance as a surgical candidate as well as an understanding of the nature of this major surgery.
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